Peter is one of the of the invasive mini surgery of the knee. He belongs to a new generation of American csotcina.comedists turned towards the and the but he has a very good knowledge of the international situation of the prosthetic joint replacement of the knee. It informs us of his innovative and somewhat personal vision of the subject.

 

MO: Peter , who are you?

P.B.: I am 47 years old, I was born in Cleveland, in Ohio, but my parents are Italian and Slovenien. They live now as Slovenia. And I have Slovenien nationality besides; I feel Européen thus completely.

MO: How can one live in Illinois, be in charge of teaching in and to have Slovenien nationality?

P.B.: Yes, indeed all that can appear a little intricate. My parents left Italy in 1950 and settled in the United States. In 1998, one proposed with my father a post of ambassador of , in the Vatican, posts that it occupied during four years. During this period, I could start a collaboration with csotcina.comedic surgeons, helped in that by my father who always kept university contacts. It is thus at that time of narrow exchanges that one proposed Slovenian nationality to me. Useless to tell you that I of course accepted. I am thus holder of a Slovenian passport and an American passport.

MO: How much languages do you speak?

P.B.: In spite of this course, I never was very good in foreign languages. I speak really only two languages, English and the Slovenien. I speak a little Italian, with difficulties but I improve gradually.

MO: Your wife is German and you have two children. Of which nationality do wish you that they be?

P.B.: , our children will be citizens of the world! We try to obtain nationalities to them Slovenien and German. We are saw that we needed more and more to spend time to Europe. We are owners of a small vineyard as Slovenia where to complicate still a little more the things, we raise a French type of vine: . My family of origin and especially the house of my father is all beside the places of burial of the last two French kings of Slovenia. The family of my father, of which a party is French, goes up until the Middle Ages. My father made his studies in Freiburg in Switzerland, where it obtained his aggregation, it states with force that he is a defender of the francophonie.

MO: And you, in this singular family, why did you choose the csotcina.comedic surgery?

P.B.: I initially chose medicine because my parents said that to have a bright future, I should be either a priest or doctor! I thus became doctor; at the time, I did not think that to become priest is an good idea! Non! And I took much more pleasure during my studies of medicine than than I could have had with the seminar… I was equipped with good aptitudes in mechanics. I studied biology and physics at the university. I am particularly interested in csotcina.comedy when I discovered that there were the prosthetic joint replacements. Then I proceeded in this way because I was persuaded that in the field of csotcina.comedy, I could look after or “to repair” people. Contrary to the other medical specialties or surgical where one delays the development of a disease without always curing it, in csotcina.comedic surgery one can really look after the patients and allow them to take again their activities.

MO: At which time you are you in the knee?

P.B.: My formation comes from my study trips. After my second and third years of boarding school, I left for Austria to learn the surgery. Then I received a fellowship to study the shoulder with Richard in , in Ontario. I then completely immersed myself in the shoulder surgery and of the upper extremity. Then to Sydney, in Australia, I followed run of Cross and Of , this formation was centered exclusively on the shoulder surgery, sporting medicine and the knee arthroscopy. Extremely of these centers of interest, I started to operate shoulders, then I dealt with all sports traumatology. And thus the things matured. As my practice progressed, I tried to associate the principles which I had learned in the field of medicine sporting and from the shoulder surgery to the arthroplasty of the knee and the hip. When my recruitment progressed I operated knees more and more. It then seemed to me that the joint replacements of the knee should profit from a less invasive approach by combining the principles of the knee surgery, the shoulder surgery, the surgery and sporting medicine. Thus we threw base invasive mini surgery of hip and knee.

MO: You direct two establishments: the Private clinic and Technologies. of these 2 structures?

P.B.: The Private clinic is an csotcina.comedic cabinet. We live in a small town which counts only 11 605 inhabitants, I settled there because we could acquire there of a vast research center in order to design new products, to make basic research as well as research and development expenses centered on new technologies. I thus moved in and, fifteen years ago of that, I opened the Private clinic, which counts seven doctors today, all having fields of specialities distinct as regards processing from the musculoskeletal system. That includes inter alia neuro-muscular pathologies, psychiatry, electromyography, the occupational medicine and the readjustment of the industrial accidents. We have also specialists in the rachis, prosthetic surgery of the upper limb as well as a specialist in sports traumatology. My competences are primarily put at the service of the shoulder surgery, the knee and the joint replacements.

MO: And Technologies?

P.B.: Technologies is a distinct splitting. It quickly appeared to us that it was important to connect the research and development expenses or more simply search and the surgical csotcina.comedic activity. We develop new technologies for the minimally invasive surgery. On the whole, approximately 180 people work within these two structures. Thus, thanks to kinesitherapy, with the electrodiagnoses, csotcina.comedy and search, engineers and researchers can work in concert, with the daily newspaper, with the clinicians, in order to try to improve the design and the development of new products.

MO: How much patients operate a year?

P.B.: Personally, I operate approximately thousand five hundred patients a year, in the hospital of called St Anthony' S Memorial. It is a regional hospital of the State of Illinois. We carry out in addition some in .

MO: Are the arthroplasties thus carried out in this structure?

P.B.: Yes. A service is provided for this purpose with St Anthony' S Memorial. Our group carries out also almost a thousand of arthroplasties a year. In this hospital, we try to develop innovating procedures which require to be fully effective the addition of several competences: a good team of anesthetists, motivated kinesitherapists and good nursing. In the same way, we test set up within the service, this famous subspecialty of invasive mini surgery.

MO: How much employees counts Technologies?

P.B.: Approximately 90, namely scientific, enquiring fundamental, engineers, engineers electro mechanics, data processing specialists but also of very invaluable people who are the milling machine operator-fitters who help us to develop the prototypes and manufacture the instruments that we use for the hip surgery and of the knee. Specific substances of rehabilitation were developed by a society which is called Joint Activates that we control.

MO: Do you still carry out surgical operations of the knee according to a conventional approach?

P.B.: These three last years, not only all the prostheses but also all the total prostheses of the knee, were operated according to noninvasive or minicomputer-invasive techniques. What means an skin incision of twelve centimetres maximum and a very economic access on the quadriceps. Certain interventions are navigate, others not. We are even currently developing a system of mini overhaul invasive. We carried out only ten with today of them, it is thus a very recent experiment. But it seems to us that these same techniques are also implemented from now on to the overhaul of arthroplasty.

MO: Why did you pass to the minicomputer-invasive joint replacement?

P.B.: I carried out traditional arthroplasties of the knee during approximately three years. When I discussed with my patients, they did not seem as satisfied as I would have supposed it. The results of their prosthesis of the knee appeared insufficient to them. When I re-examined the sporting patients with whom I had carried out a meniscectomy or a rebuilding of the , the result was very different. These patients could take again all the activities which they wished and their functional result was perfect. After installation of a knee prosthesis, even if the scores of were good and correct axial alignment, when I asked my patients if they had really found all their physical abilities, if they were able to do all that they wanted, the answer were not. When I questioned them on simple activities like putting itself at knee, to squat, climb and descend or to even rise without sorrow of a seat, I was disappointed result. The intervention seemed only not to have little improved the life of these patients.

MO: You want to say that no patient was content with his prosthesis?

P.B.: According to , a perfect score of eans that patient can install and descend a flight of stairs without using of slope and going without cane. But currently the majority of my patients require more: they want to be able to enter a bath-tub and to kneel, arrange, climb staircases without sorrow and to be able to again consider the practice of an sports activity as simple as the golf. If you ask to them whether they can install and descend a slope or collect a golf ball on a ground in descent, they are unable; they fall because their quadriceps is too weak. We compared our data concerning recovery of the quadriceps after prosthesis of the knee so that we generally observe in the surgery of the . We quantified a considerable functional loss after knee prosthesis. In our opinion, the problem can be only of three types: the implant, technique or rehabilitation. We thus stressed the technique and rehabilitation to try to restore the functional capacities of the patients and we had the certainty which this functional loss was related to the lesions undergone by the aircraft bungee cord and the damage caused with the structures of the joint capsule. When you the ball joint and that you use an access , the force of the quadriceps is reduced in a quasi final way. This phenomenon is in addition amplified by the use of the garrotte. Association, section of the quadriceps, of ball joint, inflation of the withers are a catastrophe for the effectiveness.

MO: You thus think that makes the access of it and the respect of the soft parties are more important than the implant?

P.B.: Not, I cannot affirm it, but I would say that the respect of the soft parties is as important as the axial alignment of the implant. In other words, if you injure the quadriceps, that involves a permanent lesion of the knee. Of course, no overhaul of the implant proves to be necessary since alignment is excellent, nevertheless the patient will always suffer from a functional deficit. We must not only evaluate the lifetime of the implant but also the quality of functional recovery and the requests of the patients in order to fully optimize the results of the joint replacement of the knee. I thus think and I repeat it, who the assumption of responsibility of the soft parties is quite as important as overall alignment and the position of the implant. In the past, one did not grant enough importance to it.

MO: For do these cases of minimally invasive surgery, always cement the prosthesis?

P.B.: In the United States, the tendency is clearly directed worms of the cemented prostheses . I am thus obliged to follow this rather traditional American approach. I cement the three components of the prosthesis. I think that the minicomputer-invasive techniques would be much better with an arthroplasty without cement for selected patients but, of the United States, we are limited by the FDA which does not authorize the use of certain cementless implants. But I believe that the future lies in the arthroplasty of the knee without cement.

MO: If you use an arthroplasty without cement, that means that your cuts must be perfect. Is this possible with an invasive mini approach?

P.B.: The distal cut, overall osseous alignment and the osseous cuts, can be as perfect in the minicomputer-invasive approach as in the traditional approach. I acknowledge however that it is more difficult to realize. I am sure that one can obtain an optimal fixing and a physiological alignment but it is more intricate to obtain and that requires to pay more an great attention to the surgical details. It takes you more time and you must be extremely vigilant and control the cuts stage by stage. You must in particular use miniaturized blocks of cut or a greater number of blocks of cut to adhere to the whole of the structures of the knee. But the other significant item, that the majority of the surgeons can change, it is the operational position of the knee. We do not put any more the knee in hyperflection. The majority of the intervention are carried out knee in extension, or bent between 40 and 60 degrees. We almost never bring the knee to 90 degrees, except when it is necessary to seal the final tibial component. Thus, when the knee is in extension, there is less of voltage on the soft parties and it is thus easier to reach the osseous plan and to practice precise osseous cuts. I think that navigation should facilitate that in the long run but currently it did not help me as much as I would have wished it well that I try to use it for each joint replacement of the knee. I think that navigation and the vision intended to confirm the quality of the osseous cuts will be useful auxiliary techniques in the future.

MO: How do you make in the event of ?

P.B.: Many surgeons often wonder how one proceeds to a by this channel. It is obviously about a very technical and very complex stage of the intervention. I must initially indicate that we make less since we do not luxate the hinge during the exhibition. We practice what we call of the “osseous cuts in situ”, which do not involve lesions of the posterior cruciate or a posterior capsule. , within the framework of an excellent study MRI, showed that the luxation of the hinge before practicing the osseous cuts involved a rupture of the posterior capsule. We observed the same thing: the balance is easier to regulate if you do not destroy the structures thanks to the osseous cuts in situ.

MO: How take to you there?

P.B.: The chronology is the following one: you practice the osseous cut of the tibia then femur, then one makes slip the hinge to make it available, without luxating it. If you proceed thus in a way, the gestures of balancing of the balance are simplified. The second phase consists in balancing the hinge in a sequential way. We proceed to all the , in bending with 45 degrees approximately then, in complete extension. We can the hinge thanks to a tensor and to then proceed to the remainder of the .

MO: You thus think that, to obtain a good balance of the knee, the should be preserved?

P.B.: This point remains prone to controversy. In many cases, I am not sure that the cruciate is completely normal. Sometimes, I practice only a partial of the , in other cases, one realizes that the posterior cruciate was completely divided during the operative approach. However, if you do not tear the posterior capsule, the aforementioned gives you the security of an excellent stability. In any event, we do not have any problem of instability or posterior or rotational luxation of our prostheses.

MO: Which type of implant do you use?

P.B.: I use routine the prosthesis. I like the concept of the single center of rotation antéro-posterior and médio-side. I often describe this knee like a “car-centring pin”. The base of such a knee allows at the time of the weight-bearing an adjustment of rotation and this design makes it possible to regulate balance more easily. One of the intrinsic advantages of this knee is stability .

MO: With this prosthesis which type of insert do you use?

P.B.: I use principle on all the knees an insert with conservation of the . I use in single center of rotation, which enables me to preserve the each time possible and to balance the knee correctly.

MO: You do not use a prosthesis with mobile plate?

P.B.: In the United States, there exists one concept of prosthesis with mobile plate, manufactured by Johnson & Johnson and we do not use it. This concept of mobile plate is not appropriate to me because of the weakness of the quadriceps only he induces and the bad bending obtained in the postoperative one. My main reproach concerning all the concepts of shelves rotatory is the reduction in effectiveness of the quadriceps. I want to say by there that when you put the knee in charge, the femur positions tibia behind. That decreases the moment bungee cord of the quadriceps since the ball joint moves back with the femur. We carried out preliminary tests and found a loss of effectiveness of the quadriceps which can reach 30%. I am thus savage opposing prosthesis to mobile plate.

MO: Yes. But when you practice a minimally invasive surgery, you preserve the quadriceps. Isn't this a skew to use a prosthesis with mobile plate?

P.B.: Indeed, our aim, principal are to improve the force of the quadriceps. It is sometimes difficult to evaluate with precision, the more so as when you change many variables during an operational act, you are not any more able to determine that which precedes. I will turn here towards my 10 years old clinic experiment. When I ceased using the rotatory platforms, I passed to the concept because of the improvement of fémoro-patellar kinematics, my results largely improved.

MO: Do you always carry out the patching of the ball joint?

P.B.: Yes always. We undertook a randomized exploratory study which published forever because we had to put at it a term more early than laid down. We simultaneously produced two total prostheses of the knee at the same patient. On a side, we carried out the patching of the ball joint, other not. We discovered that, up to six months, rehabilitation was faster and the patients suffered less with one not ball joint. However, at one year, the tendency was reversed, so much so that we had to revise several prostheses of the knee, simply for the ball joint. In the long run, the patching improves the functional capacities and attenuates the pains. We found a second result surprising. If there not the ball joint and that into postoperative in spite of a good rehabilitation there are a fixing or bad fémoro-patellar kinetics, there will be a big number of overhauls for pain, crackings or instability. Contrary, a on a ball joint does not affect of anything the function and the final result. A ball joint is increasingly more tolerant. In good logic, we advise always the ball joint.

MO: Let us return to the minimally invasive surgery. Where are the limits?

P.B.: Let me to you recall the history of it. In 1991, we started to develop a mini technology invasive single for the total prostheses and of the knee. And during nearly eight years, we did not find only one business firm interested in the development of invasive technologies mini. In 1999, we personally developed and miniaturized instruments and started to carry out total arthroplasties of the knee with new . Then, in the neighborhoods of 2001, we used only this technique more; we enter today more than 1000 cases - I would even tell that we are close to the twelve hundred prostheses operated by this channel and we consider this approach as revolutionist.

MO: More precisely, describe to us this access

P.B.: Firstly, skin incision. It is not a question of an basic aspect but we practice an incision of approximately 13 centimetres. You can go up to 14 or 15 provided that the other phases of the procedure remain less invasive.

Secondly, of the ball joint. And we believe firmly that “not very invasive” goes hand in hand with an extension from approximately 8% of the aircraft bungee cord what is obtained by the side wash-out of the ball joint. If the ball joint laterally and that the knee is bent with 90 degrees, one obtains a lengthening of the quadriceps of almost 16%. And if it is maintained during one hour in , that represents a too important extension for the aircraft bungee cord with a risk of sideration of the quadriceps.

Thirdly, exhibition of the quadriceps, most important point of the access. We passed from a conventional access to an external access. This direct side access enables us not to cut muscle fibers even more. It is for us the result of the invasive initially mini channel. Fourth point, osseous cuts in situ; what means that one seeks to avoid the traumatic luxation of the tibia in front of the femur. Carry out initially your osseous cuts then move the femur against the tibia.

Thus we would classify or approach the minicomputer-invasive approach, the most important point being the exhibition of the quadriceps.

MO: Which are the indications of an invasive mini surgery?

P.B.: Let us turn over the question: who can't profit from it? I see ain categories of patients. The patients forwarding of broad former incisions that we must take again, pose truly a problem. The second group understands the patients carrying a ; in these cases, it is always difficult to expose the hinge. The third group corresponds to the extremely muscular men or in overweight. In the United States, unquestionable patient can weigh up to 303 050 kilos. And if it acts men, the muscles are in general very bulky, the approach appears very . We use nevertheless an minicomputer-invasive approach, slightly amended: in other words, we practice a tiny incision because of measurements of the patient and avoid the ball joint. But I would say that they are “the worse” patients in any case, they are the most complex cases for us.

MO: How do you regulate the problem of the posterior osteophytes?

P.B.: The posterior osteophytes pose only little problem. They are removed as during a conventional surgery. It is necessary to make the femoral cuts then tibial and to put a into side. The internal osteophytes in first, then the opposite maneuvre is remade. One can also use a technique “leg hanging”. certain surgeons use this technique to make prostheses . The installation is the same one as that which one uses for sets up a medullary central nail of the tibia. It is with this installation, much easier of the hinge. We have of writing a procedure known as in suspension, the distraction being made naturally by the seriousness. Of course that takes a little more time to operate…

MO: Which is the degree of bending of the knee obtained by PUT?

P.B.: The average bending of the knee in the cases which we re-examined is of 116 degrees. It should be said that we count among our patients of the people who weigh more than ilos. In the United States, we have many obese patients. This is why our average articular amplitude is good but not as good as those published in other series of the literature. When the patients have very large thighs or very large calves, the bending is automatically blocked. Therefore, overall, our articular amplitude is good but undoubtedly could be better.

MO: Do you think that the minimally invasive surgery is really possible for this type of patients?

P.B.: I think that for the obese patients, the minimally invasive surgery is particularly important. The patients in overweight require a more powerful quadriceps to move, to climb, to rise of a seat. It is thus essential for them to preserve their function . Therefore, even if that can appear more difficult, we had the surprise to discover that in the men and obese women, the minicomputer-invasive approach is simpler to carry out than the conventional accesses. That comes from the use of the blocks of cut and the miniaturized instruments.

MO: Among these patients, don't you think that it is very easy to divide the collateral ligament accidentally knee?

P.B.: It is necessary to be very careful. In the literature, it is necessary to count approximately a lesion of the collateral ligament for 100 operated knees. On our twelve hundred total prostheses of the knee operated by minicomputer-invasive access, we never injured the collateral ligament . Out of médio-side cut, the largest risk is according to me that the oscillating saw divides part of the strip of . We even had patients suffering from tendinitis of the strip of or side pains of the knee. They are undoubtedly there main the complications which I could observe following escaped web.

MO: Remotely of did the operational act, which other complications have?

P.B.: We studied the complications of our the first 500 prostheses of the knee established by this channel. Tibial fixing is most random by far. It can prove very difficult to control an adequate pressurization of cement. Two tibial components were loosened: one obviously because of a bad technique of cementing, the other following a traumatism. I think that both are to a certain extent related to the fact that we directly did not impact the tibial component nor obtained a good pressurization of cement. That is partly with the overall dimension of the tibial keel. The second encountered problem is the position in femoral component. In our series, with the review of our first cases, when we do not expose the former femur correctly, we had tilt in bending of the femoral components, by chance, any was not revised. The third point is extremely problematic: two patients had a severe infection of the knee. That can be due to the time spent in the operating-room or the technique; I cannot say it. One of the infections was probably hematogen. But these two infections in this first series of 500 cases pose really a problem.

MO: How long the operation lasts?

P.B.: I now have good experience of the procedure. We can produce a total prosthesis of the knee minicomputer-invasive in roughly fifty minutes; we thus became with very fast time. A total prosthesis of the standard knee took generally forty-five minutes to me. The minicomputer-invasive technique thus takes only approximately inutes more to me!

MO: How did you solve the problem of installation of the tibia ?

P.B.: The keel delta of the installation can pose problems by invasive mini channel because it is very posterior. It is necessary to very bring the tibia in front of the femur at the time of sealing. It is sometimes very difficult. A smaller keel would surely help with the installation of the tibial plateau.

MO: But if you reduce the overall dimension of the keel, you will lose of stability?

P.B.: Indeed, one will lose of rotatory stability and that can induce an early unsealing. That worries me much. It is a problem which it will be necessary to evaluate and which remains in suspends.

MO: How much interventions of the knee a surgeon “” does it practice each year in the United States?

P.B.: Certain studies show that the majority of the articular replacements is carried out by surgeons who pose less than 25 prostheses of the knee a year. One thus speaks here about small activities.

MO: You thus think that the minimally invasive surgery is not intended for this type of surgeon?

P.B.: Considering their small experiment, these surgeons could encounter problems in the course of operation indeed. The majority of them can learn these techniques; it is enough that they gradually amend their practices to evolve to the technique which is appropriate to them best. It is not a question to operate from the start of the radical technical changes, we are formally opposite there. It is necessary to proceed slowly, stage by stage, and I think that the majority of the surgeons can evolve/move or improve their technique as time passes, even those which carry out only a few tens of prostheses a year.

MO: How is it possible that certain American surgeons publish series with 130° of average bending?

P.B.: According to me, these results are somewhat debatable. Technically one can proceed to certain artifices to increase the bending, although that is obligatorily made with the detriment extension. I know surgeons who give a tibial slope of 12 to 15° in the cut. When you increase the tibial slope, you increase the bending. Thus if you add ten degrees to your tibial slope, you are likely to add at least ten degrees to the bending of the knee. However, since there is reciprocal translation, you automatically lose a certain degree of extension of the knee. These surgeons who do not work that on the posterior bending always have a problem of loss of extension about which they do not speak. The second problem that I observed in the United States is the “method number two” making it possible to obtain a better bending; the aforementioned consists in installing knee prosthesis in manner . If the collateral ligaments are slackened, the bending better and is obtained more quickly. I surgically took again many knees whose bending was of 126 191 degrees, but the operator had put the prosthesis with so cowardly collateral ligaments that the prosthesis was unstable. The series of prostheses with if good performances are thus either optimistic, or the prostheses are positioned with an artifice of installation which will compromise the long-term outcome.

MO: I my question, can one rests consider 130° average bending after a ?

P.B.: Certain surgeons can speak about a bending reaching 130 degrees on average. These data are sometimes difficult to believe. I think that there exist great differences in the preselection of the re-examined cases, that you include in your study, or in the way in which you communicate or record the data, it is what can lead an operator to be able to publish results much better than those of his/her colleagues. We had a terrible feeling of frustration in the United States at the all beginnings of the minimally invasive surgery. Some among us made publications or presentations which described replacements prosthetic of hip or the installation of a knee prosthesis after which the patient returned at his place, as of the day-even. The surgeons who then tried to use this technique, encountered difficulties and especially, obviously, their patient could not leave the hospital the day-even. These same surgeons regarded themselves then as very bad or inefficient and it was not true whole. All that is a “party of marketing” associating a strict preselection of the patients, a study “very very” limited on an patient group thoroughly into postoperative. The majority of the surgeons see “standard” patients: These patients forward hinges , they suffer from serious deformations, they are in overweight, they have a certain number of associated medical problems. And if you take the average patient, your results are likely not to be as good as those which communicate fabulous results and which ensure the promotion of their prosthesis.

MO: With these important slopes, that is errors of installation in and wears of the EP?

P.B.: In fact it is increasingly more dangerous to correct alignment only in the frontal plane by not controlling the rotation of the tibia. When the posterior slope of the tibia is very important, it is necessary to be in good position in rotation of the tibial component. If you increase the slope and that rotation is abnormal, the component becomes unstable, you obtain a negotiable instrument of plane cut obliques and tibial wear and the subluxation of the components are a complication.

MO: Is navigation essential for you?

P.B.: Navigation can in certain cases being indeed very useful tools. Unfortunately, currently, navigation raises some interrogations: is it or not easy to learn, adheres to it or not the minicomputer-invasive aspect of the intervention? , is information which one receives precise with regard to balance ? I think that computerized navigation is very useful to visualize the alignment of the implant. And it can help us to control certain rotations. But I am convinced that navigation such as we use it today, without direct sensors, installed on the or on the implants, does not help us as much as technology could let it suppose, especially in the tuning of the balance . In other words, I believe that it evolves/moves and that it still takes us a few years to really obtain a “user-friendly” navigation and truly able to give us answers to the complex issues of balancing of the knee, not whom I regard as essential.

MO: What do you think of society of csotcina.comedy which disseminates commercials on the Web and on television?

P.B.: I should probably start by saying that we have ourselves a Web site on which we speak indeed about our minicomputer-invasive techniques. We however waited to have data of follow-up from at least two to four years and we initially communicated on our results in learned societies before making a negotiable instrument of ad on our Web site. I think that society which makes the promotion of their technology and direct marketing near the patients makes false route if they do not have a minimum clinical follow-up and if they do not mention the complications and difficulties of the operational act. This society endangers really the patients by forcing the surgeons to use not recognized techniques, just by negotiable instrument of mode, and I oppose it formally.

MO: What is it problems between surgeons and avocados in the United States?

P.B.: We suffer indeed from an important medico-legal problem and with a number of lawsuits always growing in the United States. To speak clearly, the avocados continue the doctors regularly. And the medical problems are not surely all to sanction. Certain surgeons in the United States pour more than 290 110 dollars a year for their only professional civil insurance. They is thus very expensive and that poses increasingly complex problems with the experts. Currently, we have the feeling which the avocados study of very close the minicomputer-invasive techniques and will attack the surgeons with the least complication. One of our problems as a promoter, resides in the fact that certain minimally invasive surgeries will be certainly the purpose continuations and that certain surgeons will undoubtedly have difficulties in justify the complications.

MO: You thus pour 290 110 dollars a year with your insurer?

P.B.: In fact the concept of fault medical professional varies from one State to another. In Illinois, the professional civil insurance is fairly raised, I pay 00 040 dollars personally a year.

MO: How such differences are possible?

P.B.: The differences are very clear from one State to another. For example, Florida and Pennsylvania have both of very bad indices of professional misconducts. That is related to the way in which the systems of insurance function in these States with prohibitory scales. In these states there the legal environment is very unfavourable to the doctors.  On the other hand, in Indiana, the amounts are very low, about 10 to 54 090 dollars, because this state protects the doctors. There is in this state a limit of the amount granted to the patient by the jury under the . The index of cost is also related to the number of businesses for professional misconduct which you lost. Fortunately, I have for the moment never have procedure for ascribable professional misconduct nor of problem of this kind, my premium account is undoubtedly a little less low. But nobody is with the shelter…!

MO: Which information do you provide to your patient with the intervention?

P.B.: We approach with our patients primarily the points concerning the results and the complications. We tell them that 5 percent of the patients can have a stiff knee or a residual pain. We mention our statistics: the rates of reinterventions or complications can reach 3 percent in our series. We speak to them about the risk of unsealing of the tibial component, of the problems due to cement, the possible loss of articular amplitude and also of stiffness, the hematomas, the risks of pulmonary embolus. We speak to them finally about the infection risk and let us inform them of the statistics we have on this subject. We try to be honest and to make read with our patients of the passages of the series published as for true rate of complications. We try to render comprehensible to them that they will have all need to follow a medical cure and a kinesitherapy and that will be able to take two to three months to obtain a complete re-establishment with an home-base kinesitherapy.

MO: Their do you give a booklet of information?

P.B.: Yes… but one of the things which helped us the most is the physical preparation preliminary to the surgery. What means that the patient meets the kinesitherapist before the beginning of the intervention, that they work together on the range of motion and the muscular reinforcement, so that the patient knows already the years and the rehabilitation which it will have to make after the intervention. We forward a video recalling to them the operation and the post-operative re-establishment and we also try to approach the techniques of anesthesia.

MO: Which amount of time runs out between the consultation and surgical operation itself? it a minimum time reserved for decision making?

P.B.: In the United States, many patients are sometimes operated the day following the consultation! However, according to our activity it is necessary to count a time from approximately six to eight weeks to plan an intervention of prosthesis of the knee.

MO: Do you think that one period of waiting is a good thing for the patient?

P.B.: I think, in particular for a nonurgent surgical intervention, that they is very although the patient can devote time - one week, two, to consider its future operation sometimes more, to speak with his/her friends, to make some search about it. In the United States, where the surgeons are not always overflowed, the operation often takes place right after the consultation. To program a one day intervention on the other provided that the insurance or the social security gives its agreement, does not seem to me to be a good thing. I think that for a nonurgent surgical intervention, the patients must take retreat, of thinking of it, to make sure that they made the good decision. I thus appreciate the French concept where the period of waiting can be fifteen days for a total prosthesis of the knee or even for any other surgical intervention.

MO: You belonged to a club gathering of the European surgeons practitioner minimally invasive surgery. Which is the difference between an Européen surgeon and an American surgeon?

P.B.: well, I find that surprising but the Européens surgeons are, according to months, more objective and more honest than American. They attentively study their data, they are more honest as for the observation of certain complications - I speak of course about the surgeons with whom I collaborated in the groups of minimally invasive surgery. And I believe that they are much more critical than are to it sometimes the American surgeons. They do not seek as much to return their home-base patients, to make them leave the hospital very quickly. That seems to me to better adapt the pain treatments, postoperative rehabilitation and to manage the continuations of the anesthesia. They consider in a more objective way the environment of the patient and analyze best the obstacles to be crossed and the potential complications. Therefore, you see, I am very impressed by the Européens surgeons with whom I worked.